Exhibit H-4 I-9 Form.pdf

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USCIS

Form I-9 OMB No. 1615-0047Expires 10/31/2022 Z:\Logos\DHS Seal Black.jpg Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services Form I-9 10/21/2019 Page of Form I-9 10/21/2019 Page of Click Start next to the section you want to complete. If you are an employee, click Section 1. If you are an Employer, click Section 2 or 3. To print this form, click the Print button in the toolbar.

Section Name Status Action Not Started Not Started Not Started Section 1. Employee Information and Attestation Section 2. Employer or Authorized Representative Review and Verification Section 3. Reverification and Rehires ►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)

.\Images\question-white\question-white.gif .\Images\question-white\question-white.gif .\Images\question-white\question-white.gif .\Images\question-white\question-white.gif Last Name (Family Name) Enter your full legal last name. Your last name is your family name or surname. If you have two last names or a hyphenated last name, include both names in this field. Examples of correctly entered last names include De La Cruz, O’Neill, Garcia Lopez, Smith-Johnson, Nguyen. If you only have one name, enter it in this field, then enter “Unknown” in the First Name field. You may not enter “Unknown” in both this field and the First Name field.

Enter your full legal first name. Your first name is your given name. Some examples of correctly entered first names include Jessica, John-Paul, Tae Young, D’Shaun, Mai. If you only have one name, enter it in the Last Name field, then enter “Unknown” in this field. You may not enter “Unknown” in both this field and the Last Name field.

First Name (Given Name) Middle Initial Your middle initial is the first letter of your second given name, or the first letter of your middle name, if any. If you have more than one middle name, enter the first letter of your first middle name. If you do not have a middle name, enter N/A in this field.

Other Last Names Used (if any) Provide all other last names used, if any (such as maiden name). Enter N/A if you have not used other last names. For example, if you legally changed your last name from Smith to Jones, you should enter the name Smith in this field.

.\Images\question-white\question-white.gif .\Images\question-white\question-white.gif .\Images\question-white\question-white.gif .\Images\question-white\question-white.gif .\Images\question-white\question-white.gif Address (Street Number and Name) Enter the street name and number of the current address of your residence. If you are a border commuter from Canada or Mexico, you may enter your Canada or Mexico address in this field. If your residence does not have a physical address, enter a description of the location of your residence, such as “3 miles southwest of Anytown post office near water tower.”

Apt. Number Enter the number(s) or letter(s) that identify(ies) your apartment. If you do not live in an apartment, enter N/A.

Enter your city, town or village in this field.

If your residence is not located in a city, town or village, enter your county, township, reservation, etc., in this field. If you are a border commuter from Canada, enter your city and province in this field. If you are a border commuter from Mexico, enter your city and state in this field.

City or Town Select the abbreviation of your state or territory from the drop-down list. You may also type the first letter of the abbreviation and use the down arrow to select your state or territory. If you are a border commuter from Canada or Mexico, you should choose your country abbreviation, located at the end of the drop-down list.

State Enter your 5-digit ZIP code in this field. If you are a border commuter from Canada or Mexico, enter your 5- or 6-digit postal code in this field.

ZIP Code .\Images\question-white\question-white.gif .\Images\question-white\question-white.gif .\Images\question-white\question-white.gif .\Images\question-white\question-white.gif U.S. Social Security Number Date of Birth (mm/dd/yyyy) Enter your date of birth as a 2-digit month, 2-digit day, and 4-digit year (mm/dd/yyyy). For example, enter January 8, 1980 as 01/08/1980.

U.S. Social Security Number Providing your 9-digit Social Security number is voluntary on Form I-9 unless your employer participates in E-Verify.

If your employer participates in E-Verify and:

1. You have been issued a Social Security number, you must provide it in this field; or

2. You have applied for, but have not yet received a Social Security number, leave this field blank until you receive a Social Security number.

Employee's E-mail Address Providing your e-mail address is optional on Form I-9, but this field cannot be left blank. To enter your e-mail address, use this format: name@site.domain. One reason the Department of Homeland Security (DHS) may e-mail you is if your employer uses E-Verify and DHS learns of a potential mismatch between the information provided and the information in government records. This e-mail would contain information on how to begin to resolve the potential mismatch. Enter N/A if you do not enter your e-mail address. You may use either your personal or work e-mail address in this field.

Employee's Telephone Number Providing your telephone number is optional on Form I-9, but this field cannot be left blank. Enter only the numbers of your 9- or 10-digit telephone number. Enter N/A if you do not enter your telephone number.

You must make a citizenship status selection.

A (See instructions) See instructions regarding an alien authorized to work.

.\Images\question-white\question-white.gif .\Images\question-white\question-white.gif .\Images\question-white\question-white.gif .\Images\question-white\question-white.gif .\Images\question-white\question-white.gif Some aliens may write "N/A" in the expiration date field.

.\Images\question-white\question-white.gif I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following boxes):

A Citizen of the United States Select this status if it applies to you. If you select this box, the rest of the fields in this area will contain N/A.

A Noncitizen National of the United States Select this status if it applies to you. If you select this box, the rest of the fields in this area will contain N/A. A noncitizen national of the United States is an individual born in American Samoa, certain former citizens of the former Trust Territory of the Pacific Islands, and certain children of noncitizen nationals born abroad.

A Lawful Permanent Resident Select this status if it applies to you. If you select this box, the fields associated with the alien authorized to work status will contain N/A.

A lawful permanent resident is an individual who is not a U.S. citizen and who resides in the United States under legally recognized and lawfully recorded permanent residence as an immigrant. This term includes conditional residents.

If you select this box, you must enter either your Alien Registration Number or USCIS Number in the field provided. At this time, the USCIS Number is the same as the A-number without the “A” prefix.

Asylees and refugees should not select this status, but should instead select “An alien authorized to work.”

Alien Registration Number/USCIS Number Lawful permanent residents must enter their 7- to 9-digit Alien Registration Number or USCIS Number here. At this time, the USCIS Number is the same as the A-number without the “A” prefix. To do so, enter the number in the space provided, then select either Alien Registration Number or USCIS Number from the drop-down. If you select Alien Registration Number from the drop-down, an “A” will appear before the number you entered.

An Alien Authorized to Work Select this status if it applies to you. If you select this box, the fields associated with the lawful permanent resident status will contain N/A. An alien authorized to work is an individual who is not a citizen or national of the United States, or a lawful permanent resident, but is authorized to work in the United States. If you select this box, you must enter the expiration date of your employment authorization, if any, and either the Alien Registration Number/USCIS Number or the Form I-94 Admission Number in the fields below.

Expiration Date of Employment Authorization Enter the date your employment authorization expires, if any, in this field. If you select this box, enter the date that your employment authorization expires, if any, in this field. In most cases, your employment authorization expiration date is found on the document(s) evidencing your employment authorization. Refugees, asylees and certain citizens of the Federated States of Micronesia, the Republic of the Marshall Islands, or Palau, and other aliens whose employment authorization does not have an expiration date should enter N/A in this field. In some cases, such as if you have temporary protected status, your employment authorization document may have been automatically extended; in these cases, you should enter the expiration date of the automatic extension in this field.

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:

An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

A .\Images\question-white\question-white.gif .\Images\question-white\question-white.gif Enter your Foreign Passport Number in this field. If you do not provide a foreign passport number, enter N/A in this field and enter either your Alien Number/USCIS Number or your I-94 admission number in the fields provided.

Click on the question mark for more information.

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OR

OR

QR Code - Section 1 Do Not Write In This Space Alien Registration Number/USCIS Number Enter your 7- to 9-digit Alien Registration Number (A-Number)/USCIS Number, if any, in this field. To do so, enter the number in the space provided, then select either Alien Registration Number or USCIS Number from the drop-down. If you select Alien Registration Number from the drop-down, an “A” will appear before the number you entered. Currently, the USCIS number is the same as the Alien number without the “A” prefix. If you do not provide an Alien Registration Number/USCIS Number, enter either a Form I-94 Admission Number or Foreign Passport Number in the fields provided. This field will then be populated with N/A.

Aliens authorized to work must enter one of the following to complete Section 1:

1. Alien Registration Number (A-Number)/USCIS Number or

2. Form I-94 Admission Number or

3. Foreign Passport Number and the Country of Issuance.

Form I-94 Admission Number Enter your 11-digit I-94 admission number in this field. If you do not provide an I-94 admission number, enter either an Alien Registration Number/USCIS Number or a Foreign Passport Number in the fields provided. This field will then be populated with N/A. Aliens authorized to work must enter one of the following to complete Section 1: 1. Alien Registration Number (A-Number)/USCIS Number or 2. Form I-94 Admission Number or 3. Foreign Passport Number and the Country of Issuance.

Foreign Passport Number Enter your foreign passport number in this field. If you do not provide a foreign passport number, enter either your Alien Number/USCIS Number or your I-94 Admission Number in the fields provided. This field will then be populated with N/A. Aliens authorized to work must enter one of the following to complete Section 1: 1. Alien Registration Number (A-Number)/USCIS Number or 2. Form I-94 Admission Number or 3. Foreign Passport Number and the Country of Issuance.

Country of Issuance If you entered your foreign passport number in the Foreign Passport Number field, select the country of issuance of the foreign passport you used to enter the United States from the drop-down list provided. You may also type the first letter of the country and use the down arrow to select your country of issuance. If you entered an Alien Registration Number/USCIS Number or I-94 admission number, or you entered N/A in the Foreign Passport Number field, this field will contain N/A.

Signature of Employee Signature of Employee - Click on the question mark for more information about this field.

After completing Section 1, sign your name in this field. If you used a form obtained from the USCIS website, you must print the form to sign your name. If you cannot sign your name, you may place a mark in this field to indicate your signature.

.\Images\question-white\question-white.gif Today's Date (mm/dd/yyyy) Today's Date - Click on the question mark for more information about this field.

After completing Section 1, enter the date you signed Form I-9 in this field. If you used a form obtained from the USCIS website, you must print the form to enter the date in this field. Do not backdate this field.

.\Images\question-white\question-white.gif Signature of Employee After completing Section 1, sign your name in this field. If you used a form obtained from the USCIS website, you must print the form to sign your name. If you cannot sign your name, you may place a mark in this field to indicate your signature. By signing this form, you attest under penalty of perjury (28 U.S.C. §1746) that the information you provided; the citizenship or immigration status you selected; and all information and documentation you provide to your employer, is complete, true and correct, and you are aware that you may face severe penalties provided by law and may be subject to criminal prosecution for knowingly or willfully making false statements or using false documentation when completing this form. If anyone other than the employee completes Section 1, both the employee and the preparer or translator should complete their respective areas of Section 1, then sign Section 1. If the employee is a minor (individual under age 18) or a person with a disability (who is placed in employment by a nonprofit organization, association or as part of a rehabilitation program) who cannot present an identity document, refer to the section of the Form I-9 instructions titled “Signature of the Employee” for more information. Employees who use a preparer or translator to complete the form must still sign or make a mark in this field.

Today’s Date (mm/dd/yyyy) After completing Section 1, enter the date you signed Form I-9 in this field. If you used a form obtained from the USCIS website, you must print the form to enter the date in this field. Do not backdate this field. Enter the date as a 2-digit month, 2-digit day, and 4-digit year (mm/dd/yyyy). For example, enter January 8, 1980 as 01/08/1980. A preparer or translator who assists the employee in completing Section 1 must enter the date the employee signed or made a mark to sign Section 1 in this field. Parents or legal guardians assisting minors (individuals under 18) and parents, legal guardians or representatives of a nonprofit organization, association or rehabilitation program assisting certain employees with disabilities must enter the date they completed Section 1 for the employee.

Preparer and/or Translator Certification (check one):

Select the number of preparers and/or translators you used to complete the form.

Click on the question mark for more information about this field.

If you did not use a preparer or translator to assist you in completing this form, you must select “I did not use a preparer or translator.” If preparers and/or translators assisted the employee in completing Section 1, the preparer or translator must select the second box marked “A preparer(s) and/or translator(s) assisted the employee in completing Section 1” and complete the rest of the fields below. This field cannot be left blank.

(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)

.\Images\question-white\question-white.png Preparer and/or Translator Certification Select the number of preparers and/or translators you used to complete the form. If you are the employee and you did not use a preparer or translator, you must select the first box marked “I Did Not Use a Preparer or Translator.” Leave the rest of the fields in this area blank. If one or more preparers or translators assist the employee in completing Section 1, the preparer or translator must select the second box marked “A preparer(s) and/or translator(s) assisted the employee in completing Section 1” and complete the rest of the fields below. The preparer and/or translator also must select the number of Certification areas needed from the dropdown provided. These additional Certification areas may result in additional pages. The first preparer and/or translator must complete the Certification on the same page the employee has signed. There is no limit to the number of preparers and/or translators that can be used, however each additional preparer and/or translator must complete and sign a separate Certification area. The Supplement for Section 1 Preparer and/or Translator provides an extra page of Certification areas, if necessary. Ensure the employee’s last name, first name and middle initial are entered at the top of any additional pages. Your employer will ensure that these additional pages are retained with your completed form. Parents or legal guardians attesting to the identity of minors (individuals under 18) and individuals attesting to the identity of certain employees with disabilities must complete this section.

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.

Signature of Preparer or Translator Signature of Preparer or Translator - Click on the question mark for more information about this field.

Any person who helped to prepare or translate Section 1 of Form I-9 must sign his or her name in this field. If you used a form obtained from the USCIS website, you must print the form to sign your name in this field.

.\Images\question-white\question-white.gif Today's Date (mm/dd/yyyy) Today's Date - Click on the question mark for more information about this field.

The person who signs the Preparer and/or Translator Certification must enter the date he or she signs the certification in this field. Do not backdate this field.

.\Images\question-white\question-white.gif Signature of Preparer or Translator Any person who helped to prepare or translate Section 1 of Form I-9 must sign his or her name in this field. If you used a form obtained from the USCIS website, you must print the form to sign your name in this field. The Preparer and/or Translator Certification must also be completed if “Individual under Age 18” or “Special Placement” is entered in lieu of the employee’s signature in Section 1.

Today's Date (mm/dd/yyyy) The person who signs the Preparer and/or Translator Certification must enter the date he or she signs the certification in this field. Do not backdate this field. If you used a form obtained from the USCIS website, you must print the form to enter the date in this field. Enter the date as a 2-digit month, 2-digit day, and 4-digit year (mm/dd/yyyy). For example, enter January 8, 2014 as 01/08/2014.

.\Images\question-white\question-white.gif .\Images\question-white\question-white.gif Last Name (Family Name) Enter the full legal last name of the person who helped the employee in preparing or translating Section 1 in this field. The last name is also the family name or surname. If the preparer or translator has two last names or a hyphenated last name, include both names in this field.

First Name (Given Name) Enter the full legal first name of the person who helped the employee in preparing or translating Section 1 in this field. The first name is also the given name.

.\Images\question-white\question-white.gif .\Images\question-white\question-white.gif .\Images\question-white\question-white.gif .\Images\question-white\question-white.gif Address (Street Number and Name) Enter the street name and number of the current address of the person who helped the employee in preparing or translating Section 1 in this field. Addresses in Canada or Mexico may be entered in this field. If the address is an apartment, include the apartment number in this field. If the person does not have a physical address, enter a description of the person’s location, such as “3 miles southwest of Anytown post office near water tower.”

City or Town Enter the city, town or village of the address of the person who helped the employee in preparing or translating Section 1 in this field.

If the address is not located in a city or town, enter the name of the village, county, township, reservation, etc., in this field. If the address is in Canada, enter the city and province in this field. If the address is in Mexico, enter the city and state in this field.

State Select the state, territory or country of the preparer or translator’s address from the drop-down list. You may also type the first letter of the abbreviation and use the down arrow to select your state or territory. If the preparer or translator entered an address from Canada or Mexico, choose the country abbreviation, located at the end of the drop-down list.

ZIP Code Enter the 5-digit ZIP code of the address of the person who helped the employee in preparing or translating Section 1 in this field. If the address the preparer or translator entered is in Canada or Mexico, enter the 5- or 6-digit postal code in this field.

Employee Name:

Employee Name - Click on the question mark for more information.

.\Images\question-white\question-white.gif Employee Name These fields will contain the employee’s name as entered in Section 1. This area allows employers to ensure that the pages of an employee’s Form I-9 remain together.

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.

Signature of Preparer or Translator Signature of Preparer or Translator - Click on the question mark for more information about this field.

Any person who helped to prepare or translate Section 1 of Form I-9 must sign his or her name in this field. If you used a form obtained from the USCIS website, you must print the form to sign your name in this field.

.\Images\question-white\question-white.gif Today's Date (mm/dd/yyyy) Today's Date - Click on the question mark for more information about this field.

The person who signs the Preparer and/or Translator Certification must enter the date he or she signs the certification in this field. Do not backdate this field.

.\Images\question-white\question-white.gif Signature of Preparer or Translator Any person who helped to prepare or translate Section 1 of Form I-9 must sign his or her name in this field. If you used a form obtained from the USCIS website, you must print the form to sign your name in this field. The Preparer and/or Translator Certification must also be completed if “Individual under Age 18” or “Special Placement” is entered in lieu of the employee’s signature in Section 1.

Today's Date (mm/dd/yyyy) The person who signs the Preparer and/or Translator Certification must enter the date he or she signs the certification in this field. Do not backdate this field. If you used a form obtained from the USCIS website, you must print the form to enter the date in this field. Enter the date as a 2-digit month, 2-digit day, and 4-digit year (mm/dd/yyyy). For example, enter January 8, 2014 as 01/08/2014.

.\Images\question-white\question-white.gif .\Images\question-white\question-white.gif Last Name (Family Name) Enter the full legal last name of the person who helped the employee in preparing or translating Section 1 in this field. The last name is also the family name or surname. If the preparer or translator has two last names or a hyphenated last name, include both names in this field.

First Name (Given Name) Enter the full legal first name of the person who helped the employee in preparing or translating Section 1 in this field. The first name is also the given name.

.\Images\question-white\question-white.gif .\Images\question-white\question-white.gif .\Images\question-white\question-white.gif .\Images\question-white\question-white.gif Address (Street Number and Name) Enter the street name and number of the current address of the person who helped the employee in preparing or translating Section 1 in this field. Addresses in Canada or Mexico may be entered in this field. If the address is an apartment, include the apartment number in this field. If the person does not have a physical address, enter a description of the person’s location, such as “3 miles southwest of Anytown post office near water tower.”

City or Town Enter the city, town or village of the address of the person who helped the employee in preparing or translating Section 1 in this field.

If the address is not located in a city or town, enter the name of the village, county, township, reservation, etc., in this field. If the address is in Canada, enter the city and province in this field. If the address is in Mexico, enter the city and state in this field.

State Select the state, territory or country of the preparer or translator’s address from the drop-down list. You may also type the first letter of the abbreviation and use the down arrow to select your state or territory. If the preparer or translator entered an address from Canada or Mexico, choose the country abbreviation, located at the end of the drop-down list.

ZIP Code Enter the 5-digit ZIP code of the address of the person who helped the employee in preparing or translating Section 1 in this field. If the address the preparer or translator entered is in Canada or Mexico, enter the 5- or 6-digit postal code in this field.

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.

Signature of Preparer or Translator Signature of Preparer or Translator - Click on the question mark for more information about this field.

Any person who helped to prepare or translate Section 1 of Form I-9 must sign his or her name in this field. If you used a form obtained from the USCIS website, you must print the form to sign your name in this field.

.\Images\question-white\question-white.gif Today's Date (mm/dd/yyyy) Today's Date - Click on the question mark for more information about this field.

The person who signs the Preparer and/or Translator Certification must enter the date he or she signs the certification in this field. Do not backdate this field.

.\Images\question-white\question-white.gif Signature of Preparer or Translator Any person who helped to prepare or translate Section 1 of Form I-9 must sign his or her name in this field. If you used a form obtained from the USCIS website, you must print the form to sign your name in this field. The Preparer and/or Translator Certification must also be completed if “Individual under Age 18” or “Special Placement” is entered in lieu of the employee’s signature in Section 1.

Today's Date (mm/dd/yyyy) The person who signs the Preparer and/or Translator Certification must enter the date he or she signs the certification in this field. Do not backdate this field. If you used a form obtained from the USCIS website, you must print the form to enter the date in this field. Enter the date as a 2-digit month, 2-digit day, and 4-digit year (mm/dd/yyyy). For example, enter January 8, 2014 as 01/08/2014.

.\Images\question-white\question-white.gif .\Images\question-white\question-white.gif Last Name (Family Name) Enter the full legal last name of the person who helped the employee in preparing or translating Section 1 in this field. The last name is also the family name or surname. If the preparer or translator has two last names or a hyphenated last name, include both names in this field.

First Name (Given Name) Enter the full legal first name of the person who helped the employee in preparing or translating Section 1 in this field. The first name is also the given name.

.\Images\question-white\question-white.gif .\Images\question-white\question-white.gif .\Images\question-white\question-white.gif .\Images\question-white\question-white.gif Address (Street Number and Name) Enter the street name and number of the current address of the person who helped the employee in preparing or translating Section 1 in this field. Addresses in Canada or Mexico may be entered in this field. If the address is an apartment, include the apartment number in this field. If the person does not have a physical address, enter a description of the person’s location, such as “3 miles southwest of Anytown post office near water tower.”

City or Town Enter the city, town or village of the address of the person who helped the employee in preparing or translating Section 1 in this field.

If the address is not located in a city or town, enter the name of the village, county, township, reservation, etc., in this field. If the address is in Canada, enter the city and province in this field. If the address is in Mexico, enter the city and state in this field.

State Select the state, territory or country of the preparer or translator’s address from the drop-down list. You may also type the first letter of the abbreviation and use the down arrow to select your state or territory. If the preparer or translator entered an address from Canada or Mexico, choose the country abbreviation, located at the end of the drop-down list.

ZIP Code Enter the 5-digit ZIP code of the address of the person who helped the employee in preparing or translating Section 1 in this field. If the address the preparer or translator entered is in Canada or Mexico, enter the 5- or 6-digit postal code in this field.

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.

Signature of Preparer or Translator Signature of Preparer or Translator - Click on the question mark for more information about this field.

Any person who helped to prepare or translate Section 1 of Form I-9 must sign his or her name in this field. If you used a form obtained from the USCIS website, you must print the form to sign your name in this field.

.\Images\question-white\question-white.gif Today's Date (mm/dd/yyyy) Today's Date - Click on the question mark for more information about this field.

The person who signs the Preparer and/or Translator Certification must enter the date he or she signs the certification in this field. Do not backdate this field.

.\Images\question-white\question-white.gif Signature of Preparer or Translator Any person who helped to prepare or translate Section 1 of Form I-9 must sign his or her name in this field. If you used a form obtained from the USCIS website, you must print the form to sign your name in this field. The Preparer and/or Translator Certification must also be completed if “Individual under Age 18” or “Special Placement” is entered in lieu of the employee’s signature in Section 1.

Today's Date (mm/dd/yyyy) The person who signs the Preparer and/or Translator Certification must enter the date he or she signs the certification in this field. Do not backdate this field. If you used a form obtained from the USCIS website, you must print the form to enter the date in this field. Enter the date as a 2-digit month, 2-digit day, and 4-digit year (mm/dd/yyyy). For example, enter January 8, 2014 as 01/08/2014.

.\Images\question-white\question-white.gif .\Images\question-white\question-white.gif Last Name (Family Name) Enter the full legal last name of the person who helped the employee in preparing or translating Section 1 in this field. The last name is also the family name or surname. If the preparer or translator has two last names or a hyphenated last name, include both names in this field.

First Name (Given Name) Enter the full legal first name of the person who helped the employee in preparing or translating Section 1 in this field. The first name is also the given name.

.\Images\question-white\question-white.gif .\Images\question-white\question-white.gif .\Images\question-white\question-white.gif .\Images\question-white\question-white.gif Address (Street Number and Name) Enter the street name and number of the current address of the person who helped the employee in preparing or translating Section 1 in this field. Addresses in Canada or Mexico may be entered in this field. If the address is an apartment, include the apartment number in this field. If the person does not have a physical address, enter a description of the person’s location, such as “3 miles southwest of Anytown post office near water tower.”

City or Town Enter the city, town or village of the address of the person who helped the employee in preparing or translating Section 1 in this field.

If the address is not located in a city or town, enter the name of the village, county, township, reservation, etc., in this field. If the address is in Canada, enter the city and province in this field. If the address is in Mexico, enter the city and state in this field.

State Select the state, territory or country of the preparer or translator’s address from the drop-down list. You may also type the first letter of the abbreviation and use the down arrow to select your state or territory. If the preparer or translator entered an address from Canada or Mexico, choose the country abbreviation, located at the end of the drop-down list.

ZIP Code Enter the 5-digit ZIP code of the address of the person who helped the employee in preparing or translating Section 1 in this field. If the address the preparer or translator entered is in Canada or Mexico, enter the 5- or 6-digit postal code in this field.

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.

Signature of Preparer or Translator Signature of Preparer or Translator - Click on the question mark for more information about this field.

Any person who helped to prepare or translate Section 1 of Form I-9 must sign his or her name in this field. If you used a form obtained from the USCIS website, you must print the form to sign your name in this field.

.\Images\question-white\question-white.gif Today's Date (mm/dd/yyyy) Today's Date - Click on the question mark for more information about this field.

The person who signs the Preparer and/or Translator Certification must enter the date he or she signs the certification in this field. Do not backdate this field.

.\Images\question-white\question-white.gif Signature of Preparer or Translator Any person who helped to prepare or translate Section 1 of Form I-9 must sign his or her name in this field. If you used a form obtained from the USCIS website, you must print the form to sign your name in this field. The Preparer and/or Translator Certification must also be completed if “Individual under Age 18” or “Special Placement” is entered in lieu of the employee’s signature in Section 1.

Today's Date (mm/dd/yyyy) The person who signs the Preparer and/or Translator Certification must enter the date he or she signs the certification in this field. Do not backdate this field. If you used a form obtained from the USCIS website, you must print the form to enter the date in this field. Enter the date as a 2-digit month, 2-digit day, and 4-digit year (mm/dd/yyyy). For example, enter January 8, 2014 as 01/08/2014.

.\Images\question-white\question-white.gif .\Images\question-white\question-white.gif Last Name (Family Name) Enter the full legal last name of the person who helped the employee in preparing or translating Section 1 in this field. The last name is also the family name or surname. If the preparer or translator has two last names or a hyphenated last name, include both names in this field.

First Name (Given Name) Enter the full legal first name of the person who helped the employee in preparing or translating Section 1 in this field. The first name is also the given name.

.\Images\question-white\question-white.gif .\Images\question-white\question-white.gif .\Images\question-white\question-white.gif .\Images\question-white\question-white.gif Address (Street Number and Name) Enter the street name and number of the current address of the person who helped the employee in preparing or translating Section 1 in this field. Addresses in Canada or Mexico may be entered in this field. If the address is an apartment, include the apartment number in this field. If the person does not have a physical address, enter a description of the person’s location, such as “3 miles southwest of Anytown post office near water tower.”

City or Town Enter the city, town or village of the address of the person who helped the employee in preparing or translating Section 1 in this field.

If the address is not located in a city or town, enter the name of the village, county, township, reservation, etc., in this field. If the address is in Canada, enter the city and province in this field. If the address is in Mexico, enter the city and state in this field.

State Select the state, territory or country of the preparer or translator’s address from the drop-down list. You may also type the first letter of the abbreviation and use the down arrow to select your state or territory. If the preparer or translator entered an address from Canada or Mexico, choose the country abbreviation, located at the end of the drop-down list.

ZIP Code Enter the 5-digit ZIP code of the address of the person who helped the employee in preparing or translating Section 1 in this field. If the address the preparer or translator entered is in Canada or Mexico, enter the 5- or 6-digit postal code in this field.

Employer Completes Next Page STOP, Employer completes next page ..\..\..\Users\Chris\Downloads\gray-image2.jpg STOP, Employer completes next page ..\..\..\Users\Chris\Downloads\gray-image2.jpg Please print to sign and date this section Employee section contains incomplete or incorrect information. Complete the highlighted areas, then select “Click to Finish”.

Section 1 Completion in Progress

USCIS

Form I-9 OMB No. 1615-0047Expires 10/31/2022 Z:\Logos\DHS Seal Black.jpg Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.") Employee Info from Section 1 Employee Info from Section 1 - Click on the question mark for more information about these fields.

These fields must contain the employee’s information as entered in Section 1.This area allows employers to ensure that the two pages of an employee’s Form I-9 remain together. The Citizenship/Immigration Status field activates certain features of Section 2.

.\Images\question-white\question-white.gif .\Images\question-white\question-white.gif .\Images\question-white\question-white.gif .\Images\question-white\question-white.gif .\Images\question-white\question-white.gif Employee Information from Section 1 These fields must contain the employee’s information as entered in Section 1. This area allows employers to ensure that the two pages of an employee’s Form I-9 remain together. The Citizenship/Immigration Status field activates certain features of Section 2.

Last Name (Family Name) This field may already contain information the employee entered in Section 1. If not, enter the employee’s last name from Section 1. If you are reverifying or rehiring the employee, enter the employee’s last name from Section 1 as he or she entered it on the employee’s original Form I-9.

First Name (Given Name) This field may already contain information the employee entered in Section 1. If not, enter the employee’s first name (if any) from Section 1.

If you are reverifying or rehiring the employee, enter the employee’s first name (if any) as the employee entered it on the employee’s original Form I-9.

Middle Initial This field may already contain information the employee entered in Section 1. If not, enter the employee’s middle initial, if any, from Section 1. If the employee entered N/A in the Middle Initial field in Section 1, enter N/A in this field. If you are reverifying or rehiring the employee, enter the employee’s middle initial (if any) or N/A as the employee entered it on the employee’s original Form I-9.

Citizenship/Immigration Status This field may already contain a number that correlates to the citizenship or immigration status box the employee selected in Section 1. If not, select from the drop-down list provided the number of the citizenship or immigration status box the employee selected in Section 1. If you have difficulty selecting the document(s) the employee presents from the drop-downs below, ensure that you selected the right number correlating to the immigration or citizenship status box the employee checked in Section 1. If this area was automatically populated, have the employee review the information he or she entered on the printed and signed copy of Section 1, make any required corrections in Section 1, then initial and date those corrections. You may then enter the employee’s corrected information in this area.

List A Identity and Employment Authorization Identity Employment Authorization

OR

List B

AND

List C .\Images\question-white\question-white.gif Use this space to notate any additional information required for Form I-9, such as:

• Employment authorization extensions for Temporary Protected Status beneficiaries, F-1 OPT STEM students, CAP-GAP, H-1B and H-2A employees continuing employment with the same employer or changing employers, and other nonimmigrant categories that may receive extensions of stay

• Additional document(s) that certain nonimmigrant employees may present that cannot be entered in the drop-downs provided

• Discrepancies that E-Verify employers must notate when participating in the IMAGE program

• Employee termination dates and form retention dates

• E-Verify case number, which may also be entered in the margin or attached as a separate sheet per E-Verify requirements and your chosen business process

• Any other comments or notations necessary for the employer’s business process

You may leave this field blank if the employee’s circumstances do not require additional notations.

Additional Information Enter the expiration date, if any, of the document or receipt you entered in the first Document Title field. A document is not acceptable if it has already expired. An unexpired document includes a document where the expiration date shown on the face of a document has been automatically extended, such as for individuals with Temporary Protected Status.

If the document uses text rather than a date to indicate when it expires, enter the text shown on the document, such as “D/S” (which means, “duration of status”). If the document does not contain an expiration date, enter N/A. If the employee presented a combination of documents, use the second and third Expiration Date fields as necessary. For a receipt, enter the expiration date of the receipt validity period.

1. For a receipt showing that the employee has applied to replace a document that was lost, stolen or damaged, enter the date that is 90 days from the first day of work for pay.

2. For a receipt that is the arrival portion of Form I-94/I-94A containing a temporary I-551 stamp and a photograph of the individual, enter the expiration date of the stamp or, if there is no expiration date, within one year from the date of admission.

3. For a receipt that is the departure portion of Form I-94/I-94A with a refugee admission stamp, enter a date that is 90 days from the first day of work for pay.

Expiration Date #1 List A Document Number #1 List A Enter the document number, if any, exactly as it appears on the document you entered in the first Document Title field. If you chose a receipt in the Document Title field, you should enter the receipt number, if any, exactly as it appears on the receipt. If the document does not contain a number, enter N/A. If the employee presented a combination of documents, use the second and third Document Number fields as necessary.

Select from the drop-down list the issuing authority of the List A document or receipt you entered in the first Document Title field. The issuing authority is the entity that issued the document. If the employee presented a List A document that consists of a combination of documents, use the second and third Issuing Authority fields as necessary. If the issuing authority provided in the drop-down list does not match the issuing authority shown on the document presented, ensure that you made the correct selection in the Document Title field.

Issuing Authority #1 List A Document Title #1 List A If the employee presented documentation from List A, select the document or receipt presented from the drop-down list provided. If the employee presented a List A document that consists of a combination of documents, select the first document from the drop-down list provided. The other documents in the combination should be entered in the separate areas provided.

All documents must be unexpired. Ensure that each document is an unexpired, original (no photocopies, except for certified copies of birth certificates) document. Certain employees may present an expired employment authorization document, which may be considered unexpired, if the employee’s employment authorization has been extended by regulation or a Federal Register Notice. Refer to the instructions for more information.

The documents below the dotted line in the drop-down are unacceptable for the citizenship or immigration status the employee selected in Section 1. If you receive an error message after selecting one of these documents, ensure that you selected the correct number in the Citizenship/Immigration Status field that correlates to the citizenship or immigration status box the employee checked in Section 1. If this area was automatically populated, have the employee review the information he or she entered on the printed and signed copy of Section 1, make any required corrections in Section 1, then initial and date those corrections. You may then correct the number in the Employee Info field, which should provide the correct list of acceptable documents.

If the employee did not present a List A combination document, the second and third Document Title fields will contain N/A.

An entry in this column allows all fields in the List B and C columns to contain N/A. If you did this in error, select a document from the drop-down list provided in List B. All fields in the List A column will then contain N/A, and you will then be able to complete the List B and List C columns.

Enter the expiration date, if any, of the document or receipt you entered in the second Document Title field. The document or receipt is not acceptable if it is already expired.

If the document or receipt does not contain an expiration date, enter N/A.

If a combination of documents was not presented and N/A was entered in the Document Title #2 field, this field will also contain N/A.

If the document uses text rather than a date to indicate when it expires, enter the text as shown on the document, such as D/S (which means, duration of status).

Expiration Date #2 List A Document Number #2 List A Enter the document or receipt number, if any, exactly as it appears on the document or receipt you entered in the second Document Title field. If the document or receipt does not contain a number, enter N/A. If a combination of documents was not presented and N/A was entered in the Document Title #2 field, this field will also contain N/A.

Select from the drop-down list the issuing authority of the List A document or receipt you entered in the second Document Title field. The issuing authority is the entity that issued the document.